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Skin cancer risk factors

The key risk factors for skin cancer are discussed on this page. Skin cancer risk is also linked with age and sex

Skin cancer includes malignant melanoma of the skin (malignant melanoma of other body organs, e.g. eye, are not included), and non-melanoma skin cancer (NMSC); NMSC is comprised of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC).

Around 86% of malignant melanomas in the UK are linked to lifestyle.1

Meta-analyses and systematic reviews are cited where available, as they provide the best overview of all available research and often take study quality into account. Individual case-control and cohort studies are reported where such aggregated data are lacking.

Skin cancer risk factors overview

The International Agency for Research on Cancer (IARC) evaluates evidence on the carcinogenic risk to humans of a number of exposures including tobacco, alcohol, infections, radiation, occupational exposures, and medications.4 The World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) evaluates evidence for other exposures including diet, overweight and obesity, and physical exercise.134 IARC and WCRF/AICR evaluations are the gold standard in cancer epidemiology. Their conclusions about skin cancer risk factors are shown in Table 4.1.

Table 4.1: IARC and WCRF/AICR Evaluations of Skin Cancer Risk Factors

Increases risk ('sufficient' or 'convincing' evidence) May increase risk ('limited' or 'probable' evidence) Decreases risk ('sufficient' or 'convincing' evidence) May decrease risk ('limited' or 'probable' evidence)
  • Solar radiation
  • Ultraviolet-emitting tanning devices (malignant melanoma)
  • Cyclosporine (NMSC)
  • Coal tar pitch and distillation
  • Mineral and shale oils
  • Soot
  • Arsenic and inorganic arsenic compoundsa
  • X radiation, gamma radiation (BCC)
  • Azathioprine (SCC)
  • Methoxsalen plus UVA
  • Polychlorinated biphenyls (malignant melanoma)
  • Ultraviolet-emitting tanning devices (SCC) (malignant melanoma)
  • HIV type I (NMSC)
  • Creosotes
  • Nitrogen mustard
  • Petroleum refining
  • Selenium supplements

-

  • Retinol supplements (SCC)

Classification for all skin cancer types (malignant melanoma and NMSC) unless otherwise specified.
a Arsenic in drinking water classified by WCRF/AICR as a probable cause.

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Age and sex

Skin cancer risk is associated with age and sex.

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Ultraviolet (UV) radiation from sun exposure

Exposure to solar UV radiation is classified by IARC as a cause of skin cancer (melanoma and NMSC).3,4 An estimated 86% of malignant melanoma cases in the UK are linked to solar UV radiation.1 An estimated 50-70% of SCC and 50-90% of BCC in fair skinned people are caused by radiation.5

Malignant melanoma risk is more closely linked with intermittent exposure to high-intensity sunlight (e.g. sunbathing or holidaying in a place with strong sunlight), than to chronic sunlight exposure (e.g. being in an outdoor occupation), a meta-analysis has shown.6

Intermittent sun exposure and sunburn

Malignant melanoma risk is 60% higher in people with the highest level of intermittent sun exposure, compared with those with the lowest, a meta-analysis showed; however this effect was limited to populations outside the UK, US, Canada or Australia.6

Malignant melanoma risk is more than doubled in people with a history of sunburn (often caused by intermittent exposure to high-intensity sunlight6), compared with people who have never been sunburned, meta-analyses have shown.6,7 Malignant melanoma risk is increased by 2-3 times in women who had 26+ 'painful' or 'severe' sunburns in their lifetime, a pooled analysis showed.8 Malignant melanoma risk is increased regardless of whether sunburn occurred in childhood or adulthood.8,9

BCC risk - and, to a lesser extent, SCC risk - is higher in people with a history of sunburn (especially in childhood) or intermittent exposure to the sunlight.10,12,14-16,130

26% of men and 33% of women in Britain actively try to get a tan, data from 1999 showed; rates were even higher in younger people.24 Holidays abroad by UK residents have become increasingly popular in recent decades.135 Climate changes may increase the strength of solar radiation and lead to more time spent in direct sunlight (due to warmer weather), with possible consequences for skin cancer incidence rates.98 The impact of sunscreen use on skin cancer risk remains unclear, due largely to methodological limitations and other behaviours which may accompany (and perhaps counteract) sunscreen use.43-48

Sunbathing, tanning or burning should not be necessary to make sufficient vitamin D to obtain health benefits.

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Chronic sun exposure

Malignant melanoma risk does not appear to be associated with chronic sunlight exposure, a meta-analysis showed; however occupational sun exposure still probably increases risk over no sun exposure at all.6

BCC risk is 43% higher in people who work outdoors, compared with those who do not, a meta-analysis showed.17 SCC risk is 77% higher in outdoor workers compared with indoor workers, a meta-analysis showed.18 These associations are stronger in countries nearer the equator.17,18

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Ultraviolet (UV) radiation from sunbeds

Use of UV-emitting tanning devices (e.g. sunbeds) is classified by IARC as a cause of melanoma; and as a probable cause of SCC, based on limited evidence.3,4 An estimated 100 malignant melanoma deaths each year in the UK are caused by sunbed use.19,21

Malignant melanoma risk is 16-25% higher in people who have ever used a sunbed (at any age), compared with sunbed never-users, meta-analyses have shown, though risk may vary by region.19,103,136 Malignant melanoma risk is 59% higher in people who first used a sunbed before age 35, compared with sunbed never-users, a meta-analysis showed.103

SCC risk is at least 67% higher in people who have ever used a sunbed (at any age), compared with sunbed never-users, meta-analyses have shown.19,101 BCC risk is up to 29% higher in people who have ever used a sunbed (at any age), compared with sunbed never-users, a meta-analysis showed.19,101 BCC risk is 40% higher in people who first used a sunbed before age 25, a meta analysis showed.101 Malignant melanoma and BCC risk are increased in people who have ever used a sunbed even if they have not been burned while doing so, case-control studies have shown.22,23

2% of adults in Britain trying to get a tan do so using a sunbed/tanning machine only, data from 1999 showed.24 5-6% of teenagers and young adults use or have used sunbeds, data from 2008 and 2009 showed.25,26 Sunbed use by under-18s is banned in Scotland, England and Wales, and Nothern Ireland.

Sunbed use may be particularly dangerous for children; for people with skin phototypes I or II, many moles (naevi), a history of frequent childhood sunburn, pre-malignant/malignant skin lesions, or sun-damaged skin; and for people wearing cosmetics or taking medications which may enhance their UV-sensitivity.27,28 In addition to increased skin cancer risk, sunbed users may also be at increased risk of eye damage, photodermatosis, photosensivity and premature skin ageing.27

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Skin type, hair and eye colour

Malignant melanoma risk is more than doubled in people with skin phototype I compared with people with skin phototype IV (Table 4.2), a meta-analysis showed.29 Malignant melanoma risk is around doubled for all skin phototype II, and 35% higher for skin phototype III compared with skin phototype IV, a meta-analysis showed.29

Table 4.2: Skin Phototypes

Skin Phototype Typical Features Tanning Ability
Type I Tends to have freckles, red or fair hair, and blue or green eyes. Often burns, rarely tans.
Type II Tends to have light hair, and blue or brown eyes. Usually burns, sometimes tans.
Type III Tends to have brown hair and eyes. Sometimes burns, usually tans.
Type IV Tends to have dark brown eyes and hair. Rarely burns, often tans.
Type V Naturally black-brown skin. Often has dark brown eyes and hair.  
Type VI Naturally black-brown skin. Usually has black-brown eyes and hair.  

Based on: Fitzpatrick T. Soleil et peau. J Med Esthet 1975;2:33-4.

section reviewed 19/07/13
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Malignant melanoma risk is 57% higher in people with blue/blue-grey eyes, compared with dark-eyed people, a meta-analysis showed.29 Malignant melanoma risk is 51% higher in people with green/grey/hazel eyes, compared with dark-eyed people.29

BCC and SCC risk is higher in people with blue/green-blue/green-grey eyes, compared with dark-eyed people, a cohort study showed.34

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Malignant melanoma risk is up to tripled in people with red/red-blonde hair, compared with dark-haired people, meta-analyses have shown.29,32 Malignant melanoma risk is doubled in blondes, and 46% higher in people with light brown hair, compared with dark-haired people, a meta-analysis showed.29

BCC and SCC risk is higher in people with red and light-coloured hair, compared with dark-haired people, a meta-analysis and cohort studies have shown.35-37

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Malignant melanoma risk is around doubled in people with freckles, compared with people without freckles, a meta-analysis showed.29 This is independent of their number of moles.33

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Moles (naevi)

Malignant melanoma risk is around 4-10 times higher in people with any unusually shaped or large moles (also called atypical naevi; these are usually larger than common naevi, with a more variegated appearance; poorly-defined border, and some areas slightly raised), meta-analyses show.38,39 Malignant melanoma risk is nearly 7 times higher in people with a large number (100+) of common moles, compared with people with very few (0-15 moles), a meta-analysis showed.38 Malignant melanoma risk increases by around 2% for every additional common mole, a meta-analysis showed.39

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Most moles are genetically determined, appearing during childhood or adolescence.33,41,42 Sun exposure can increase the number of moles, with chronic sun exposure more influential than number of sunburn episodes.33

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Family history and genetic conditions

Family history

Malignant melanoma risk is around doubled in people with a family history of the same disease, versus people without such a family history, meta-analyses and a cohort study have shown.56,57,132 Risk is highest if the affected relative is aged under 30, or more than one first-degree relative is affected, a cohort study showed.132 Inherited risk accounts for around 10% of malignant melanoma cases.58,59

SCC risk is increased in people with a family history of the same disease, a cohort study has shown.63 BCC risk is increased in people with a family history of malignant melanoma, a cohort study has shown.64

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Genetic conditions

Malignant melanoma risk is higher in Europeans with CDKN2A mutation, characteristic of familial atypical multiple mole melanoma (FAMMM); around 6 in 10 develop malignant melanoma by age 80.60,61

Malignant melanoma and NMSC risk may be increased in Li Fraumeni syndrome.62

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Previous cancer

Malignant melanoma risk is 8-15 fold higher in people with a previous malignant melanoma, multiple cohort studies have shown,65,66,116,131 the effect is stronger for women.65,66 Malignant melanoma risk is 30-fold higher in people with a previous malignant melanoma and a parent with malignant melanoma.67

Malignant melanoma risk is up to doubled among people with a previous diagnosis of various other cancers, including female breast cancer;68,69 non-Hodgkin lymphoma;70,71 renal cell carcinoma;72 certain childhood cancers;73,115 prostate cancer;68,74,125 thyroid cancer;68 and leukaemia.68 Often these associations are bi-directional,66 supporting shared genetic or environmental factors.

BCC and SCC risk is ten times higher in people with previous SCC.75-77 BCC risk is ten times higher in people with previous BCC. SCC risk is inflated to a lesser extent in BCC survivors.75-77 NMSC risk is three times higher in people with previous malignant melanoma.78

section reviewed 14/04/14
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Medical conditions and treatments

The immunosuppressants azathioprine and cyclosporine, and the eczema treatment methoxsalen+UVA, are classified by IARC as causes of SCC, NMSC, and all skin cancer types, respectively.4 The immunosuppressant nitrogen mustard is classified by IARC as a probable cause of skin cancer, based on limited evidence.4 Increased skin cancer risk in some medical conditions may be linked with use of these treatments.

Organ transplant

Malignant melanoma risk is doubled in organ transplant recipients, a meta-analysis and cohort studies have shown.80-82

NMSC risk is 29-fold higher in organ transplant recipients, a meta-analysis and cohort studies have shown.80-82

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Crohn's disease

Malignant melanoma risk is 80% higher in people with Crohn's disease, a meta-analysis shows.107 Malignant melanoma risk is 23% higher in people with ulcerative colitis, a meta-analysis shows.107 This risk increase appears to be independent of treatment.107

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Atopy and allergy

NMSC risk is increased in people with atopic dermatitis (the most common form of eczema), cohort studies show.83,84

NMSC risk may be very slightly decreased in people with contact allergy.85

NMSC risk may be 7 times higher in people with severe psoriasis, compared with the general population, a cohort study showed.113

Malignant melanoma risk may be 11 times higher in people with severe psoriasis, a cohort study showed.113

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Parkinson's disease

Malignant melanoma risk is apparently doubled in men with Parkinson’s disease, but there is no significant association for women, a meta-analysis showed.86 Subsequent cohort studies have found a smaller effect (41%-53% increase in men and women combined) with similar magnitude in both sexes.121,124

NMSC risk may be associated with Parkinson's disease, but evidence remains mixed.86,121

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Rheumatoid arthritis

NMSC risk is probably not associated with rheumatoid arthritis treated with tumour necrosis factor inhibitors (anti-TNF-α), but the evidence remains unclear, meta-analyses have shown.87,109 Among rheumatoid arthritis patients, skin cancer risk does not vary by treatment type.87,99

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Infections

Human immunodeficiency virus (HIV)

HIV type 1 infection is classified by IARC as a probable cause of NMSC, based on limited evidence.4 Malignant melanoma and NMSC risk is increased in people with HIV or AIDS, a meta-analysis has shown.80

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Human papillomavirus (HPV)

BCC risk is 30% higher in people diagnosed with genital warts (associated with infection with HPV types 6 and 11), a cohort study showed.102

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Height

Malignant melanoma risk is 17% (females) and 13% (males) higher per 5cm height increment, a pooled analysis of Nordic data showed.127

NMSC risk is 12% (females) and 10% (males) higher per 5cm height increment, a pooled-analysis of Nordic data showed.127

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Overweight and obesity

Malignant melanoma risk is 31% higher in overweight (body mass index (BMI) 25-29.9) and obese (BMI 30+) men, compared with men whose BMI is lower than 25, a meta-analysis showed.108 Risk may plateau in overweight men,108 but evidence is unclear.89 Malignant melanoma risk may not be associated with BMI in women,89,90,108 however, this may reflect mutual confounding between body size and sun exposure (e.g. larger women self-limit their public sun exposure).108

BCC risk is 26-43% higher, and SCC risk is 20-41% higher, in women with BMI lower than 25, compared with larger women, US cohort studies have shown.34,91 Again this may reflect self-limited public sun exposure in larger women.91,118

Early onset malignant melanoma risk is more than doubled in people weighing 4.5-6kg at birth, compared with those weighing 3-3.5kg at birth, a cohort study showed.114

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Ionising radiation

X radiation and gamma radiation are classified by IARC as causes of NMSC.4

Radiotherapy for a previous cancer is estimated to have caused 17.9% of second primary malignant melanoma cases in women and 2.8% of second primary malignant melanoma cases in men in 2010.92 Malignant melanoma or NMSC risk is 14% higher in people who receive at least one computed tomography (CT) scan of the brain before age 20, with no significant effect of CT scans to other anatomical sites, a cohort study showed.112

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Occupational exposures

Coal tar pitch, soot, mineral oils and shale oils, arsenic and inorganic arsenic compounds are classified by IARC as causes of skin cancer, and polychlorinated biphenyls are classified as a cause of malignant melanoma.4 Creosotes and petroleum refining are classified by IARC as probable causes of skin cancer, based on limited evidence.4

An estimated 7% (males) and 1% (females) of NMSCs in Britain are due to occupational exposures (including solar radiation).95

Malignant melanoma risk is increased among airline staff, meta-analyses have shown; this is probably due to excessive UV exposure and sun-sensitive skin phenotypes rather than exposure to cosmic radiation.93,94

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Factors shown to decrease or have no effect on skin cancer risk

Retinol (vitamin A from animal sources) supplements are classified by WCRF/IACR as possibly protective against SCC.134

WCRF/AICR make no judgment on the association between skin cancer risk and potatoes; non-starchy vegetables; fruits; fish; eggs; milk; total fat; cholesterol; coffee; tea; alcohol; protein; vitamin A; retinol (foods); folate; vitamin C; vitamin D; vitamin E; multivitamins; selenium; carotenoids; beta-carotene (melanoma); alphacarotene; lycopene; physical activity; body fatness; and energy intake due to limited evidence.134 Beta-carotene is classified by WCRF/AICR as unlikely to have a substantial effect on NMSC risk.134

Skin cancer risk is not associated with the following factors, meta- and pooled analyses or systematic reviews have shown:

  Malignant melanoma NMSC
Oral contraceptives No association96 No association122
Hormone replacement therapy No association96 Some evidence of increased risk122
Age at first birth, number of children Any association largely explained by socio-economic factors96 -
Tobacco smoking No association4,110 Evidence unclear97,110
Alcohol No association133 Some evidence of increased risk117,126
Non-steroidal anti-inflammatory drugs (NSAIDs) No association (though some evidence of risk reduction with aspirin use)104,105 -
Low fat diet No association111 -
Folate from supplements No association106 -
Vitamin A and carotenoids No association119 -
Omega-3-fatty acids - No association128
Statins No association129 No association129

Evidence not available for both malignant melanoma and NMSC for all factors shown.

 section reviewed 10/04/14
section updated 10/04/14

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References for skin cancer risk factors

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